i say copro for pres with bougie as veep.
The first thing I would do is completely phase out Medicare/Medicaid. Over the next 40 years (yes,
forty). It's taken a long time to get us to where we are, and it's going to take a long time to extricate ourselves. They way it would work is that we'd stop having new college graduates pay into the system, and they would not be eligible to receive benefits when they retire.
The second thing I would do is create a two-tiered system of full government write-off with incentive (meaning 125% tax break) for those paying into a health savings account. You would actually get
more credit for paying into such a system (>$1 for each dollar contributed) on your annual taxes. This would be capped at a certain amount per year, but the result would be that you get a significant tax break for what you choose to contribute.
The next thing I would do is punish, with additional tax burden, those who choose not to pay into such a system. Hey, if all you offer is a carrot and no stick, then some people won't opt to go for the carrot without the threat of being hit. This would be in the form of an additional tax paid into a catastrophic healthcare fund that can't be touched by any government bureaucrat for other uses. Hospitals that have a large burden of unpaid bills every year could apply to have reimbursement of their unpaid expenses through this fund (not all of it) through whatever was in this account.
After that, I would create a system where you could get an
additional tax break for having an annual check-up with a primary healthcare provider.
Next, I would create a system where insurance companies could not collectively bargain, and hide their individual rates they charge, with employers and hospitals anymore. This also would be two-tiered. The first tier would require that individuals would be mandated to hold their own policy and, much like car insurance, pay a premium directly to the insurance company. Again, the person owning the policy would be able to write-off 125% of this cost on their annual taxes. The second tier would require open publication by the companies providing that insurance what their rates paid to physicians and healthcare organizations are. For example, if they reimburse St. Elsewhere Outpatient and Dr. Haywood Jablome $400 for a colonoscopy, and they reimburse Podunk Community and Dr. Hal Duzmiazmel down the street $500 for the same procedure, everyone would know it - including the doctors providing the services.
Lastly, you would get an estimate up front about how much your hospitalization will cost, after you get your preliminary diagnosis. (Don't think that's feasible? Well, then you don't know about the DRG... which is
already how Medicare operates.) If you come into the hospital for an emergency, you will be required to put a deposit down (say, $100) and after the doctor sees you, stabilizes you, and tells you what he/she thinks the problem is, you get an estimate for how much it's going to cost to fix it. If that estimate strays more than 20% above the actual cost, that hospital eats it. Mechanics can do this when they fix your car.
Trust me when I tell you that hospitals have a pretty damn good idea what your final bill will be when you enter the door. Why don't they provide this information to you when you arrive?
Dentists already do this too. This would make care better all the way around. It would force doctors not to keep patients in the hospital unnecessarily (to churn billing). It would reduce unnecessary testing. And, the "stick" in this is that you still would get sued if you get inadequate care. Patients have a right to know what their presumptive diagnosis is and how much that hospitalization will cost, with a high degree of certainty, when they walk in the door. If you run into a complication, they also have a right to know why and how much additional cost it will be before you provide them additional treatment.
We don't have these conversations with patients when they come in the door because we have this lofty notion that we are there to make them better, no matter what. We also don't have these conversations because we
have no earthly idea how expensive (i.e. what we bill) our treatments and tests we offer are.
At the end of the year, you can see who's racking up huge charges compared to the patient's outcome. You'd probably wouldn't be surprised that some of the crappiest doctors result in some of the biggest charges for a variety of reasons. And, they often have worse outcomes. You identify these individuals and subject them to either additional training (in the form of CME, etc.), or dismissal from the hospital. We're talking about averages here, and we have the ability to identify trouble makers, from patients to care givers, but why we don't routinely do it - or, for those healthcare systems that do, why they don't use that information to effect change - is a mystery to me.
This is ultimately a business, folks. And, the goal of that business is to provide the best care to the most people in the most cost-effective way. We need to divorce ourselves from this lofty and paternalistic notion that those two things are separate. We could learn a
huge lesson from
how dentists operate in that regard.
-copro
